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Please fill out this application completely by typing or using black ink.
Application For: ___ 10 month program ___5 month program Entry Date: ___August ___January Student Name ____________________________________________________
Last First Middle

Permanent address: ____________________________________________________
Street address

Please enclose 2 passport-size smiling color pictures.

City Country Postal Zone

Telephone: __________________________________________
Country Code City Code Home Number

Birthplace: _______________________________________________ Date of Birth ___/___/___
City Country Month/Date/Year

Citizenship: __________________ Nationality ________________ Age ____ Gender ___F ___M Height _________ Weight: _________ Hair Color: ____________ Eye Color: ____________

Country issuing passport _________________ Passport number _______________ Expires __/__

Please check in the answer applies: Mother Father Parents

I live with:

___ Living ___ Living ___ Separated ___ Deceased ___ Deceased ___ Divorced
Last Name Address Home Telephone First Name Postal Zone Business Telephone/Fax

___ Mother ___ Father ___ Grandmother ___ Grandfather ___ Other please explain _________________
Occupation City Country

Father ____________________________________________________________________________________ __________________________________________________________________________________________ _______________________________________________ Speaks English:

___ Yes

___ No

Mother ___________________________________________________________________________________
Last Name Address Home Telephone First Name Postal Zone Business Telephone/Fax Occupation City Country

__________________________________________________________________________________________ ___________________________________________ Speaks English:

___ Yes

___ No

Please list any other members of your household Name __________________________________________ __________________________________________ __________________________________________

Age Gender Relationship ______ ___________ _______________________ ______ ___________ _______________________ ______ ___________ _______________________

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Please tell us about yourself:
What is your religious affiliation? ______________________________________________ When do you participate? ___ Weekly Do you ever smoke? ___ Montly ___ Holidays ___ Never


___No Can you adjust to a home where other smoke? ___Yes


Do you like animals? ___ Yes Indicate your 5 favorite sports:
 ___ Aerobics ___ Basketball ___ Gymnastics ___ Ice Hockey ___ Skiing-Snow ___ Track/running


List any pets you have at home _______________________________

___ American Football ___ Archery ___ Badminton ___ Bicycling ___ Camping ___ Field Hockey ___ Hiking/Backpack ___ Horseback Riding ___ Ice Skating ___ Martial Arts ___ Roller-skating ___ Skiing-Water ___ Soccer ___ Swimming ___ Tennis ___ Volleyball ___ Windsurfing

___ Baseball ___ Fishing ___ Hunting ___ Sailing

___ Golf ___ Skating

Indicate your 5 favorite interests
___ Attending Sporting Events ___ Dancing-Ballet, Classical ___ Gardening ___ Listening to Popular Music ___ Photography ___ Playing Team Sports ___ Singing ___ Chess ___ Computers ___ Cooking ___ Debating ___ Drama-Theater ___ Flower Arrangement ___ Going to the Movies ___ Handicrafts ___ Knitting ___ Listening to Classical Music ___ Painting-Drawing ___ Playing Indoor Games/Cards ___ Playing Musical Instruments ___ Playing Individual Sports ___ Reading ___ Scouts ___ Sewing ___ Social Dancing ___ Visiting Museums ___ Watching Television

Indicate your 5 personality traits which best describe you.  ___ Active ___ Adaptable ___ Bright ___ Charming


___ Calm ___ Cheerful ___ Communicative ___ Considerable ___ Curious ___ Emotional ___ Enthusiastic ___ Extroverted ___ Flexible ___ Formal ___ Friendly ___ Humorous ___ Independent ___ Informal ___ Intellectual ___ Intelligent ___ Introverted ___ Intuitive ___ Kind ___ Mature ___ Motivated ___ Natural ___ Neat ___ Open ___ Optimistic ___ Organized ___ Patient ___ Pessimistic ___ Polite ___ Quiet ___ Realistic Relaxed ___ Reliable ___ Reserved ___ Respectful ___ Responsible ___ Sense of Humor ___ Sensitive ___ Serious ___ Shy ___ Sincere ___ Smiling ___ Spontaneous ___ Stable ___ Stubborn ___ Studious ___ Talkative ___ Tolerant ___ Traditional ___ Well-Mannered Unique interests and skills: ___________________________________________________________________________________________


List musical instruments you play ___________________________________________________________ List Foreign Languages you speak Language Years of Study Proficiency English ___________ __________________________________ _______ ___________ __________________________________ _______ ___________ __________________________________ What grade in school are you currently attending? ________ Next year? ________________

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1. Give at least two reasons why you want to study in the United States (besides the benefits of improving your English). ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ 2. List at least two aspects about your own culture that you want to share with your friends in the USA. ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________

3. Describe your career goals and how you plan to achieve them. ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ 4. Describe a personal achievement of which you are particularly proud. ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ 5. What do you think will be three most difficult problems you will encounter? How you will deal with them? ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________

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I. DANGEROUS ACTIVITIES. DRIVING. Skydiving, hang gliding, glider riding, parachute jumping, parasailing, jet skiing, and
riding in hot air balloons are prohibited. Student will not be allowed to drive a motorized vehicle for which an operator's license is required

II. DRINKING. DRUGS. SMOKING.. The drinking of alcoholic beverages, including beer and wine, is against program regulations..
Failure to obey this regulation may result in dismissal from the program and the student being returned to his/her home country. Student will not be permitted to smoke while on the program The student is required to refrain from using drugs of any kind (other than prescribed drugs for health purposes). Further, no association is to be maintained with anyone involved with drugs or drug use in any way. Any student who breaks this rule will be returned to his/her home country immediately.

III. EXTENSIONS. A student may extend his/her program by applying and paying the difference in fees plus the established surcharge. Any
student extending his/her stay beyond the scheduled return will be considered terminated from the program and the Immigration and Naturalization Service will be notified that Sponsor is no longer responsible for the student.

IV. FINAL AUTHORITY. Students must respect all decisions made by the Sponsor, its representatives or stuff and the School. Sponsor
reserves the right to dismiss a student from the program should the student violate the Standards of Conduct or for other disciplinary problem.

V. HITCH-HIKING. Hitch-Hiking is extremely dangerous. Students are not permitted to hitch-hike, either alone or with friends. VI. LAW VIOLATIONS. If a student admits to a criminal law violation, or is arrested and charged, or if reliable information is received that
the student will be arrested and charged, the student will be returned to his/her home country as soon as legally possible. Students are expected to obey all laws of the host country, state, city and community.

VII. LEAVING THE PROGRAM. A student may not leave the program at any time without the express written permission of Sponsor and
School. Refunds will not be made except in cases of emergency. The student may leave the program due to death or serious illness in the immediate family or for other bona fide emergency situations as determined by Sponsor.

VIII. SCHOOL. The student must attend school regularly and obey all school rules.. The student is expected to show an interest in his/her
school work and make an effort to do his/her best.. If, in the school's opinion, the student needs a language tutor to succeed in classes, Sponsor will arrange for such a tutor. The cost for tutoring will be sole responsibility of the student's natural parents. Dismissal from school due to lack of attendance or for disciplinary reasons, will also result in dismissal from the program.

IX. SEX. Student is to refrain from sexual behavior and activity. Student found to be pregnant or responsible for a pregnancy will be sent home

X. TELEPHONE. For the long distance telephone calls Student must use a telephone card. XI. TRAVEL. Students must have a round trip ticket from his home country. Students will be permitted to travel while in the host country only
according to the following conditions:. Only School and group--sponsored trips are permitted. School must approve all trips.. If independently to visit another family, the inviting family must confirm the invitation with the School. Unauthorized travel may be cause for dismissal from program.

XII. WORK AND JOBS. It is against the law for a student to hold a job or seek employment.

We, the student and parents, have read and understand all of the above. We agree to obey these rules and understand that disobeying them will result in the student's dismissal from the program and being returned to his/her home country. _________________________________________________ _____________________
Signature of Student Date

Signature of Father or Legal Guardian


Signature of Mother or Legal Guardian


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We, the undersigned, as the participant, and the parent(s) or legal guardian(s) of a participant in a program organized and d irected by the Program Sponsor, its Officers, Board of Directors, Agents, Representatives and Schools where the participant may be assigned, from any and all current and future claims, charges, costs and/or causes of action for loss or property, personal injury, illness, accident or death sustained by the participant for the duration of the Sponsor program, whether covered by current insurance or not. We further understand and agree we are responsible for any loss, damage or injury caused by the participant in the Sponsor exchange program. We understand and agree that the participant will be subject to the authorities and teachers of the school where he/she may be assigned and that he/she must follow the rules set forth by the Host Family with whom he/she may live. We have read and understand the Standards of conduct and agree that the participant must follow and abide by these rules and regulations as outlined. As the parent(s) or legal guardian(s) of the participant we agree to supply our child with sufficient spending money to cover his/her needs and expenses for the duration of his/her exchange program. We understand and agree that Sponsor is not responsible for my/our child's money or personal property, whether lost or stolen, while he/she is participating in the Sponsor exchange program. Further, we understand and agree that should there be a geographic move of my/our child, for any reason whatsoever, the cost of transportation shall be borne by the participant. We grant Sponsor permission to use photographs, or any other materials in which the participant may appear, for promotion or publicity of the organization's future programs. If we have personally misrepresented, or have knowledge of misrepresentation of any portion of this application, we understand and agree that the Sponsor program and repatriating the participant. In the event of repatriation, we shall bear all costs incurred and that any and all program fees are non-refundable.

Signature of Student


Signature of Father or Legal Guardian


Signature of Mother or Legal Guardian


I/we understand that my/our child's Program Sponsor program terminates one week following the closure of school or at the time of his/her group departure and return to their home country. Sponsor does not accept any responsibility for students who remain within the USA as tourists for longer than the stipulated period of time.

Signature of Father or Legal Guardian


Signature of Mother or Legal Guardian


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Student Name ____________________________________________________________________________ Date of Birth ___/___/___

City and Country of Birth _____________________________________

(This examination is to be done by a Medical Doctor) Height ______________ Weight _______________ Blood Pressure ______________ Pulse ______________ Visual Acuity Without Correction R _____/_____ L _____/_____ With Correction R _____/_____ L _____/_____ Hearing R_____/_____ L_____/_____

Respiratory System _________________________________________________________________________ Cardiovascular System ______________________________________________________________________ Neurological system ___________________________________________________________________________ Musculoskeletal System ______________________________________________________________________ Urinalysis S.B. ________________ Alb ______________Sugar _____________Micro ___________________ E.N.T. ____________________________ Liver ____________________ Spleen ________________________ Abdomen _________________________ Skin ________________________ Genitals ____________________ Comment regarding abnormalities _____________________________________________________________ Significant past illness or injury _______________________________________________________________ Please specify any allergies ___________________________________________________________________ Medication currently being taken ______________________________________________________________ Additional comments _________________________________________________________________________

Please state "yes" or "no" if any of the following relates to the student. f you answered "yes", please explain on a separate sheet. YES Measles ________ Rubella ________ Mumps ________ Allergies ________ Eye problems ________ Hospitalization ________ Pulmonary disease_____ Cardiac disease ________ Endocrine disorder_____ NO _______ _______ _______ _______ _______ _______ _______ _______ _______ Chicken Pox Kidney disease Congenital anomalies Menstrual disorder Orthopedic problems Convulsions Neurological disorders Accidents Operations YES _______ _______ _______ _______ _______ _______ _______ _______ _______ NO _______ _______ _______ _______ _______ _______ _______ _______ _______

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(This section is to be completed by a Medical Doctor) Student Name __________________________________________
VACCINE AND DATE OF DOSE POLIO (Trivalent Oral -- TOPV) DPT (Difteria, Tetanus & Pertussis or Whooping Cough) or TD (Tetanus & Difteria) MEASLES (Rubeola, 10-day measles) MUMPS RUBELLA (German Measles, 3 day measles) BACILLUS CALMETTE-GUERIN (BCG) TB SKIN TEST (Mantoux) CHEST X-RAY (Radiograph)-- If TB Skin Test is positive, the student must have a chest X-ray. m/d/y / / / / / / / / / / / / / / / / / / m/d/y / / / / / / / / / / / /

Date of Birth ___/___/___
Month/Date/Year m/d/y / / / / / / m/d/y / / / / / / m/d/y / / / / / /

Comments: Results: Positive Negative Results:

POLIO 4 doses 3 doses by 1 year of age 4-th dose at 4 years of age before 7 years of age booster required within past 10 years


4 doses 4 doses

MMR -- two doses 1st dose after 12 month of age 2nd dose after age 10 negative result no evidence of TB If positive, clear chest x-ray required Required if TB skin test is positive

Please list any sports or physical activities in which this student should NOT participate: ________________________________________________________________________________________________ I, the undersigned physician, have given this student a thorough physician examination and reviewed the medical history of this student. I certify all important medical information has been included (attach separate sheets, if necessary) and the above information is complete and accurate. Physician's full name (please print) ____________________________ Telephone: ____________________

Complete address ___________________________________________________________________________ Physician's signature: _______________________________________ Date: ________________________

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In case of illness, accident, or injury, I/we grant permission to Program Sponsor, its representatives, the school where my/our child is enrolled to authorize examination and treatment for my/our child, by qualified medical personnel. I/we also grant Sponsor, the school where my/our child is enrolled all necessary permissions to act as legal guardians, especially in emergencies, whether medical or other, including surgical operations or any other treatment. This authorization also grants permission to release information regarding my/our child in order to receive any and all inoculations or immunizations required by federal, state, local, and/or school authorities for participation in the Sponsor's program. This Medical Release Authorization shall be valid for the entire duration of the Sponsor's program in which my/our child is participating. ________________________________________________
Signature of Father or Legal Guardian


Signature of Mother or Legal Guardian


I/we authorize Program Sponsor, its representatives, and the School to allow my/our child to travel, within the guidelines as established in the Sponsor's Standards of Conduct. It is understood that this authorization is signed in advance and eliminates the necessary of obtaining our signature(s) at the time of any Sponsor approved travel for the duration of my/our child's participation in this program. _________________________________________________
Signature of Father or Legal Guardian


Signature of Mother or Legal Guardian


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Student Name ________________________________________________ Country ____________________
Last First Middle

Name of person completing form ___________________________________ Title ___________________ In English, please list grading scale next to the corresponding American grades listed on the left. AMERICAN GRADING SCALE Excellent Above Average Average Poor Fail A B C D E FOREIGN GRADING SCALE __________________ __________________ __________________ __________________ __________________

COMMENTS ____________________________________ ____________________________________ ____________________________________ ____________________________________ ____________________________________

Year 19___/___ School Grade _______ Courses Week __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ Hours/ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ Grade _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ Year 19___/___ School Grade _______ Courses Week ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ Hours/ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ Grade _______ _______ _______ _______ _______ _______ _______ _______ _______ _______

Year 19___/___ School Grade _______ Courses Week __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ Place Official School Stamp Here Hours/ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ Grade _______ _______ _______ _______ _______ _______ _______ _______ _______ _______

Year 19___/___ School Grade _______ Courses Week ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ Signature Hours/ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ Grade _______ _______ _______ _______ _______ _______ _______ _______ _______ _______

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(To be completed by student's teacher or counselor in English) Thank you for completing this form for the below-named applicant, who wishes to spend an academic semester or a year, living with a family abroad and attending high school. Student Name ____________________________________________________________________________
Last First Middle

Name of person completing form _________________________________________________________ Indicate your position at the school: ___Principal ___Counselor ___Teacher(Subject) _______________

Name and Address of School _________________________________________________________________ _________________________________________________________________________________________ Type of School: ___Private ___Public ___Religious ___Boarding

Please rate the student in the following categories: EXCELLENT GOOD Academic Ability _________________ ___________ __________ Academic Performance _____________ ___________ __________ Attitude toward school _____________ ___________ __________ Study habits _____________________ ___________ __________ Initiative ________________________ ___________ __________ Emotional stability ________________ ___________ __________ Maturity ________________________ ___________ __________ Adaptability / Flexibility ___________ ___________ __________ Leadership capabilities _____________ ___________ __________ Cooperativeness __________________ ___________ __________ Friendliness ______________________ ___________ __________ Relationship with teachers _________ ___________ __________ Relationships with classmates _______ ___________ __________ FAIR _________ _________ _________ _________ _________ _________ _________ _________ _________ _________ _________ _________ _________ POOR _________ _________ _________ _________ _________ _________ _________ _________ _________ _________ _________ _________ _________

How many years have you known this student?

_________ ___Yes ___No

Does this student have a history of continuos absence from school?

Please elaborate your above ratings of the student. How would you evaluate his/her potential success as an exchange student? ________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ___________________________________________________________________________ Signature __________________________________________ Date ___________________

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(To be completed by English teacher or Sponsor's Representative) Please circle the score (1 to 10) which best describes the student's ability to understand and speak English. Use the guidelines next to each score for your evaluation. Student Name ____________________________________________________________________________
Last First Middle

Name of Interviewer ____________________________________________ Position __________________

10 9 8 7 6 5

Absolute proficiency in English. Student is able to both understand and converse, dealing with
abstract terms. Thinks in English

Student possesses near fluency. Sentence structured are near perfect. Can understand and
respond to difficult questions. English knowledge includes abstract terms. Will have no problem at all in communication when he/she arrives in the USA.

English responses, although not perfect, come naturally. In other words, student
responds evidently in English. Has good vocabulary and understands almost everything. Can respond intelligently, but needs practice.

Student can understand most. Speaking ability is good, but needs practice. Student can go
beyond basic responses and elaborate thoughts. Knows many words, but needs to think before responding.

Student understands basic English. Vocabulary deals with everyday common terms. Thinks
quickly, but evident that he/she is translating. Gets lost when conversation departs from basics. makes mistakes, but is understandable. Can carry on conversation.

Student can understand much more than he/she can communicate, however makes an effort. Can respond in some sentence forms even if grammar and structure are not


Student evidently understands basic English sentences and is able to respond even if only in words. Grammar and sentence construction are poor but understandable. A few
weeks of total immersion in English will improve his/her ability.

3 2 1

Student understands words, but not sentence thoughts. Speaking ability is limited to a
few words.

Student understands a few words, but has little or no ability to communicate.
Student may also refuse to use English

Student can not understand and knows little or no English.

Please give your reasons for this score and any suggestions you may have for this student. _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ Signature __________________________________________ Date ___________________

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